Works with the providers and clinic staff to identify patients at high risk Supports longitudinal care of the patient with chronic care conditions by: Performing assessment of health conditions  Performing medication reconciliation  Conducting Motivational Interviewing and Self-Management Goal setting  Providing patient education, creating referrals to appropriate agencies and resources Supports transition of the patient with chronic care conditions from inpatient to outpatient setting, by: Performing assessment of transitional needs Performing medication reconciliation Establishing and reviewing contingency plan Providing patient education Assisting with post discharge needs such as prescriptions, transportation, Durable Medical Equipment (DME), appointments Coordinate with providers to establish or update plan of care Performs accurate and timely documentation in the electronic medical record Participates in daily huddles and Patient Care Coordination (PCC) meetings Prepares accurate and timely reports, as required, for weekly meetings Maintains continued competence in nursing practice and knowledge of current evidence-based practices May perform clinical tasks within their scope of practice